Financial Assistance Program

My Life Counsel's Financial Assistance Program is made possible through the My Life Counsel benevolence fund, community donations and grants are used to offset the cost of therapy for families in need. This is a significantly limited funding source, and careful consideration is placed on this stewardship process.

The board of directors must approve submissions. Approval can take up to seven days.

Financial Assistance Program Application

1. First and last name of person(s) responsible

2. Phone

3. Email

4. List name, relationship, and ages of household occupance

6. Source of income and/or place of employment

7. Do you have insurance?

8. Spouse, Partner, or any Adult income contributor's Income Source

9. Please write a brief explanation of your financial hardship.

10. Who is your current therapist or who provided you with this application?

11. By checking the boxes below, I understand and agree to the Financial Assistance Program’s guidelines and policies. Required

1. To my knowledge, all of the statements and choices on this form are accurate and true.

2. All session reschedules and/or cancellations that are less then 36 hours will be considered a charged session.

3. More than three reschedule and/or cancellations will result in a discharge, and a “payback” process will ensue.

4. A debit or credit card must be on file for guideline noncompliance.

Thanks for submitting!